The Bone Scandal

If a woman breaks a bone after menopause, a clear warning of osteoporosis, it should set off all sorts of alarms with her doctor.

Why doesn't it?

Unfortunately, this experience is all too common for women, say a growing number of experts who call this widespread failure to diagnose and treat osteoporosis after a fracture a near scandal.

The Washington, DC-based National Osteoporosis Foundation recommends that adults who suffer a low-trauma fracture (such as breaking a bone after falling from ground level or a low height) have a bone-density test followed by medications if necessary.

"But 75% of these fractures in the US do not get followed up by diagnosis or treatment," asserts endocrinologist John Bilezikian, MD, a Prevention advisor and director of the Metabolic Bone Diseases Program at Columbia-Presbyterian Medical Center in New York City. "In virtually all the reports published in the past few years, physicians who deal directly with the fracture event rarely take appropriate action to diagnose and treat osteoporosis."

This happens despite the availability of highly accurate diagnostic tests and drugs that can help prevent the bone deterioration that often leads to more fractures.

"When an adult fractures a bone, it should be a call to action to prevent the next one," says Dr. Bilezikian, who notes that the vast majority of fractures in adults over age 40 are associated with osteoporosis and are highly predictive of future fractures. "Having a fracture at least doubles your risk of sustaining another fracture within a year."[pagebreak]

Three Studies Bear Negligence

In one study of 1,162 women over age 65 being treated for distal radial (forearm) fractures, only 2.8% were sent for bone-density testing to evaluate and document the presence of osteoporosis, and only 22.9% received any subsequent anti-osteoporosis medical treatment.

Among 170 elderly patients with hip fractures treated in a large New York City teaching hospital, only 3% were referred for bone-density testing, and only 5% were prescribed calcium, vitamin D, or bisphosphonate medication, such as Fosamax and Actonel, which can help prevent fractures.

And in a US study of more than 200,000 postmenopausal women ages 50 and older, published in the Journal of the American Medical Association, found that nearly half had thinning bones and didn't know it.

Fewer than one-third of all cases of osteoporosis have been diagnosed, and only 1/7 of American women with osteoporosis receive treatment, according to the American Association of Clinical Endocrinologists in Jacksonville, FL.

Why It's Happening

One common reason why many physicians are currently "dropping the ball on osteoporosis," says Dr. Bilezikian, is a "mindset that their job is just to fix the fracture" and "an outdated notion that there's nothing we can do to prevent the next one."

Many physicians were not trained in osteoporosis care and prevention, notes Washington, DC, orthopedic surgeon Laura L. Tosi, MD, chairperson of the Rosemont, IL-based American Academy of Orthopaedic Surgeons' Women's Health Issues Committee. "But that's changing as we're working to alert orthopedists that a fracture is a big-time warning sign."All too often, a woman with a wrist fracture will end up getting a hip fracture later on," she says. "And serious fractures can result in a loss of independence." An estimated 30% of patients with a hip fracture become permanently disabled.

Inadequate federal funding for research has also been a problem, notes Dr. Tosi, who says early osteoporosis studies "offered a maze of conflicting protocols." Costs frequently present barriers to proper care too, she says. Although Medicare covers bone-density testing, Dr. Tosi notes that "in order to take the most effective preventive action, the best time for the first bone-density test is at the onset of menopause, which usually occurs many years before the patient is eligible for Medicare." Plus Medicare doesn't pay for medications that can prevent the disease from progressing.

Many health insurers won't cover the $140 cost for the most accurate bone density test, called a dual-energy x-ray absorptiometry (DEXA), which measures the spine and hip. But some will pay for less-expensive ($40 to $60) ultrasound tests that measure the heel or wrist.

In addition, many patients, and some doctors, don't realize that healthy bones generally don't break when someone falls from a standing position, says endocrinologist Carolyn Becker, MD, associate director of the Toni Stabile Osteoporosis Center at Columbia-Presbyterian Medical Center in New York City. "Unless you're in a high-trauma situation, such as falling off a ladder or getting hit by a truck," she says, "a fracture usually means there's some problem with the quality or quantity of bone."[pagebreak]

What Women and Doctors Don't Know

Other myths surround the disorder. "Many women think taking calcium is sufficient to prevent osteoporosis, or they think supplements such as glucosamine will help, neither of which is true," says rheumatologist Timothy Harrington, MD, director of the University of Wisconsin Medical Foundation's Bone Density Center in Madison. While healthy lifestyle behaviors such as sufficient calcium intake, exercise, and not smoking are essential to optimum bone health, he says they are not a substitute for medications in postmenopausal women at greatest risk.

Doctors also may have mistaken beliefs about osteoporosis treatment, he says. "Some physicians still believe that hormone replacement is an effective treatment for osteoporosis," notes Dr. Harrington. "But its main role in bone health is to prevent bone loss in early postmenopausal women at risk."

For women with osteoporosis, he adds, bisphosphonates have been shown to reduce vertebral, hip, and long-bone fractures in women by 50 to 90%. And other promising treatments are expected to be widely available soon, including parathyroid hormone.

The most important message, Dr. Harrington says, is that "women need to understand that they have to be advocates for their own best health care. When it comes to getting diagnosis and treatment, you can't take no for an answer."

1. Get a Prescription If a bone-density test and a complete medical workup indicate osteoporosis or osteopenia (somewhere between strong bones and osteoporosis), diet and exercise alone won't halt further bone loss. Several drugs can slow or stop the bone-thinning process. Your doctor can help you decide if one of them is right for you.

3. Get Appropriate Exercise Regular exercise is crucial for every woman. Without it, your bones thin automatically. Here's what you need:

If you have osteoperosis: Certain movements can be harmful, so consult with a knowledgeable doctor. Consider an exercise video designed for women with osteo.

If you have healthy bones or osteopenia: Get regular weight bearing exercise, such as jogging, walking, and dancing, plus resistance exercise, such as weight lifting with either free weights or weight machines.

4. Bone-Density Tests In general, the lower your bone density, the higher your risk for fracture. These tests that measure bone density are painless and safe. In most cases, you don't even need to undress.

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